(2) The obstruction of an artery--_e.g._, by septic thrombosis--has prevented the blood from reaching a part of the brain, with similar results to those mentioned.

(3) In other cases are found the more or less extensive changes produced by meningitis or meningo-encephalitis. The inflammation of its envelopes has interfered with the brain, and consequently with its functions.

(4) An increased secretion of cerebro-spinal fluid has led to a compression of the nervous system or a distension of its cavities, notably of the lateral ventricles of the cerebral hemispheres, and has led to a separation of the bones of the cranium, thus producing the large globular head of hydrocephalus.

(5) There may be found simply defects of development whose causes are known (microcephalus, or extreme smallness of the cranium relatively to the face; microgyria, or marked thinness of the convolutions).

(6) Lastly--and this is frequently the case in the worst degrees of deficiency--the post-mortem, and even microscopic examination of the organs may show no change at all.

Let us add that the nature of the lesions just mentioned does not seem to have any relationship to the condition of the mental faculties. An anatomico-pathological grouping of the cases and a grouping according to the mental condition, far from being parallel, are frequently decidedly different. On the other hand, the extent of the lesions is of more importance. Diffuse lesions affect the mind more than those which are circ.u.mscribed--that is to say, limited to a certain part of the brain--as if the mental functions required the co-operation of the entire cerebral cortex. One will often find, for example, sound judgment in the subject of a marked paralysis, whilst it is very rare to find that good intelligence co-exists with any degree of microcephalus.

Let us emphasise the last fact we mentioned, the absence of any lesion. Some authorities have maintained that all conditions of mental deficiency and want of balance found in children are connected with definite diseases of which they are the symptoms. The question is unsettled. For our own part we adopt the following provisional statement: Mental deficiency and want of balance are peculiar mental conditions which it is often impossible to connect with definite pathological changes.

Thus, we do not know of any medical treatment which is likely to act upon the preceding lesions when they are present, and we do not think it is even possible to act upon them.

An exception must, however, be made of conditions due to insufficient secretion of certain glands. The type of these is cretinism. Marked cases of this condition are easy to recognise. The very appearance of the children is sufficient for an experienced eye--the stunted growth; the rough, wrinkled skin; the swollen eyelids half-concealing the eyes; the prominent belly; and the mental apathy. One also comes across abortive cases, where the above-mentioned characters are less marked; the sluggishness also is less. These latter cases are amenable to the same treatment as the former--namely, the ingestion of thyroid glands from the sheep.

This treatment stimulates growth and makes the child more lively; but what ultimately becomes of the cases so treated? The amelioration usually ceases whenever the treatment is dropped. But how far does this amelioration go? To what extent does the child profit by it?

Lasegue has jocularly remarked that the average duration of an attack of typhoid fever (six weeks) represents the maximum time during which medical attention could be brought to bear upon a patient. One feels disposed to think he is right in face of the slight satisfaction one can obtain from the literature regarding a point of such importance.

Other cases of mental deficiency may be due to an alteration in the pituitary gland. It is for the doctor to find out whether there are any symptoms by which mental deficiency of such an origin can be recognised, and whether it is possible to prepare a suitable substance for replacing the absent secretion.

The number of cases amenable to treatment of this kind is, unfortunately, very limited.[13] We may even say that, as a general rule, we did not find amongst the school children we examined any cases of obesity or infantilism such as are sometimes described of a truly remarkable nature. Even children who were abnormally short looked their age. We have still, however, to mention one last influence--namely, poverty. Its part in the production of mental debility is scarcely defined. What are the exact effects upon intelligence of prolonged deficiency of nutrition? How can its action be isolated from that of other agents, such as alcoholism, which too frequently accompanies it? The complexity of such social studies sufficiently explains their present incompleteness. Let us recall the results we obtained from an inquiry of this kind; the children of parents in extreme poverty are r.e.t.a.r.ded in their physical development more frequently than those whose parents are in easy circ.u.mstances. It is interesting to add that a.n.a.logous inquiries with reference to intelligence have furnished similar results.

Apart from the preceding cases, the best that can be done is to treat the symptoms. The two princ.i.p.al agents at the disposal of the doctor are the bromides and hydrotherapy. Unfortunately, if the bromides are undoubtedly efficacious in certain cases of epilepsy, that is far from being the case in simple want of mental balance, in which cases they are at best useful adjuvants. As to hydrotherapy, and especially cold douches, their princ.i.p.al indication is in certain nervous affections, where their effect is to enable the subject to master the emotional reactions which are habitually exaggerated.

Lastly, the doctor can exert his moral influence to a.s.sist the educative work of the teacher in the special school. His less frequent intervention, the different motives of his advice, will often give him even more authority than the teacher. The suggestive effects of his intervention should be obtained, in our opinion, without resort to hypnotism.

=3. Does the Mentally Defective suffer from any Definite Illness?=--If the illness such as we have referred to affects those parts of the cerebral cortex which govern the muscles of a limb, one will find, in addition to the mental condition, paralysis with atrophy and contracture. But in addition to such very marked cases, there exist others in which sensory or motor affections, although slight, may hinder the progress of education.

It goes without saying that if a child does not profit from the school work, an examination of his sight and hearing should be made as a matter of course. Perhaps that may have been done already by the teacher himself by such methods as he is able to use. But this first examination is not sufficient. The doctor must correct, as far as possible, the want of acuity noticed. No doubt the defect may not explain the mental deficiency of the child, but one must take care that in the school for defectives a p.r.o.nounced myopia or catarrh of the middle ear does not prove an obstacle to the efforts which are to be made to bring about development.

In the same way it must be considered whether the condition of the muscular system is such as to permit the manual work which one wants to teach the child, and whether there exists any paralysis or tremor which would prove an obstacle to work of this kind. One must consider whether any symptoms present are transitory, like ch.o.r.ea; or permanent, like infantile hemiplegia; and what kind of efforts may be made without risk to the health of the child. Such are the problems which the doctor has to solve.

In the last place, it is necessary to take into account the coexistence with the mental deficiency of other affections.

_Epilepsy._--Epilepsy frequently coexists with mental deficiency. Now, epilepsy does not always reveal itself by severe fits with crying, falling down, loss of consciousness, convulsions, stiffness followed by jerking of the limbs, foaming at the mouth, biting of the tongue, and involuntary pa.s.sage of urine. It is revealed also by symptoms of a less striking nature, which have been described under the name of _pet.i.t mal_. Such are loss of consciousness, vertigo, or simply mental perturbations. Loss of consciousness occurs without the tremor of a muscle, the child suddenly turns pale, loses consciousness for a moment, and then continues whatever he was doing--for example, walking or writing. There is nothing more impressive to notice when the fit occurs as one is talking to the little patient. One sees, as it were, the pa.s.sing of a veil. But nothing could be more fugitive, nothing could more easily escape the notice of anyone who was not a good observer. Often the parents know nothing about it. The attacks are so short, the consequences apparently so slight, that even if the parents have chanced to notice them, they do not always think of mentioning the fact. The teacher of defective children ought to be instructed in the characteristics of this affection. He is going to spend several hours daily with the children. He will have the best opportunities for noticing the occurrence of attacks, which may be rare, but which, when they occur, are very significant.

Although the symptoms are a little more marked, vertigo also is of brief duration. To the pallor and the loss of consciousness of the preceding condition there is added a little muscular relaxation. The child totters, supports himself by anything in his neighbourhood, slips down in his seat, or drops his pen. Sometimes there is a slight spasm of the muscles of the face, the mouth is drawn to one side by slight jerks, or performs some movements of mastication or deglut.i.tion. And that is all--no convulsions of the limbs, no pa.s.sage of urine, scarcely an interruption to the work which is being done.

Whether the doctor discovers these symptoms by interrogation of the parents, or whether the teacher some time afterwards describes them to him with sufficient detail to permit of a certain diagnosis, a double gain results. In the first place, there is an indication for treatment; and in the second, the possibility of supervision. As a matter of fact, it too frequently happens that these symptoms, little dramatic as they are, reveal the existence of epilepsy, which will ultimately result in progressive mental decadence.

And yet this is not all. A few days or a few hours before such symptoms occur, or immediately after them, or, lastly, according to some authorities, entirely independently of them, the patient may develop a peculiar condition of irritability, in which he will transgress against discipline, make insolent remarks, or even give way to violence. Such actions ought not to be suppressed by punishment, because they are of morbid origin.

All such symptoms possess this characteristic, that they leave no trace on the memory of the child. He himself knows nothing about them, or knows them only by what he has heard from other people. There can now be no need to insist with what care inquiries must be made, especially of the parents.

Are epileptics to be admitted into the special cla.s.s? On principle they are refused admission to the ordinary school. They are, however, to be found there. There are those whose attacks occur very rarely, or are so slight as to cause no disturbance. There are probably also unrecognised cases of epilepsy in which the symptoms occur during the night, or on awakening, but never in cla.s.s. Only the severe forms are turned away. Probably the same state of affairs will recur in the cla.s.ses for the abnormal--at any rate until the time when provision for epileptics is more extensive than it is at present. It will therefore be necessary to recognise these cases, to supervise them with special care during certain kinds of manual work, and, if possible, to treat the nervous symptoms suitably while the patients are receiving instruction.

_Hysteria._--Although hysteria has not the same gravity, it is no less advisable that cases should be tracked out. This neurosis is being discussed to-day as never before. Without setting forth at length what we think should be included under this term, let us point out a characteristic of hysteria which is commonly recognised, and which is of such importance that it indicates the line of treatment to be followed. The two princ.i.p.al manifestations of the affection, hysterical fits and the recital of lying tales, require for their complete development the presence of a public, of a gallery.

Inversely, their disappearance is a.s.sured by isolation or apparent inattention.

The discovery of such tendencies before entrance to the school will allow the doctor to forewarn the teacher, and point out to him the best way of dealing with such children.

There are still three affections about which we must say a few words--rickets, adenoid vegetations, and scrofula.

_Rickets._--The chief characteristic of this condition is defective ossification. Instead of possessing their usual rigidity, the bones become curved, and multiple deformities result. The legs become bowed, and the knees cannot be brought into contact when the feet are placed together; the thorax becomes constricted or gibbous, etc. In addition to the nutritive disturbance, which appears to be at the root of all these disorders, there may be, according to some authors, an affection of the entire system, and especially of the nervous centres.

Unfortunately, as rickets is a disease of the earliest years of life, one often finds oneself in the presence of the sequelae which have been left, and which simply must be made the best of.

_Adenoid Vegetations._--Everyone has now heard of cases of this kind where the appearance is so characteristic. The lips are always half open, the appearance is sleepy-looking, the respiration is difficult.

If one looks at the throat, or if one introduces the finger into the child's mouth in order to explore the pharynx behind the soft palate, one will see or feel the large tonsils or the fleshy ma.s.ses which obstruct the posterior orifice of the nasal fossa. One would like to find in these vegetations the cause of the habitual torpor of the children, and of their want of progress. It is true that there is a connection between mental backwardness and adenoids. The removal of the swellings by a surgical operation will make more free the respiration, whose obstruction prevented sustained attention, and will also frequently cure the deafness, which was due to an obstruction of the Eustachian tubes. The operation may therefore result in a marked amelioration of the mental condition as well as of the general health.

If the amelioration is sufficient, the child can be sent back to the ordinary school.

_Scrofula, Tuberculosis._--A child with a lymphatic appearance, whose tissues are infiltrated with serum, and whose glands readily become enlarged, requires plenty of country air and a nutritious diet. If he is admitted to the special school, it will be advisable to attend to his health before subjecting him to any particular educational methods.

The doctor, then, will notice in pa.s.sing the existence of such conditions as rickets, adenoids, and scrofula in the children who are submitted to him. Affections of the lungs and tuberculosis of the bones will also attract his attention. But such affections in abnormal children have no other significance than in the case of children of average intelligence. They furnish no special indication regarding the admission or non-admission of the child into a special cla.s.s. Their severity alone determines the course to follow with respect to their treatment.

We shall, however, say a few words about another infirmity--incontinence of urine. If there is presented for a cla.s.s for defectives a subject, eleven years of age, who cannot control himself in this respect, the course to follow is: submit the child to examination by a specialist, who will decide the nature of the incontinence. If it is curable, give the condition the necessary attention, or give instructions at the school for training the child properly; but if there is an incurable weakness of the sphincters, supply the child with the same kind of apparatus as is used in such cases by ordinary people.

Here, then, are a number of important points upon which the doctor may be called to give his opinion. It is he alone who is able, by his special knowledge, to enlighten the other members of the jury. If the mental condition is doubtful and requires further observation, it is for him to point it out. One will thus avoid the mistake of placing in a cla.s.s for defectives a lunatic, or a child poisoned by alcohol, who would not find there the kind of care required. If the bodily condition discovered complicates or aggravates the mental deficiency, as adenoid vegetations may do, he will prescribe the proper treatment.

If he suspects the coexistence of some neurosis, he will give directions by which the condition may be recognised, and consequently treated. The doctor therefore has to recognise the physical and mental ailments by which the defective may be affected. He makes this diagnosis for two reasons. In the first place, in order that mental deficiency may not be confounded with conditions of illness of a different kind; and, secondly, in order to relieve or cure if possible coexisting affections which may aggravate the condition of the children and interfere with the work of the school.

We shall conclude here what we have to say about the role of the doctor, since in this volume we are specially concerned with the recognition and segregation of the children. To discuss the role of the doctor quite fully would take us too far.

The details we have given show that the part of the doctor with regard to defectives is quite different from that of the teacher. It is not so much to determine the child's precise mental level as to diagnose the condition of his brain, and to discover, by a.n.a.lysis of all the symptoms, the original responsible agent. That, however, is the second part of the doctor's work, and is of scientific interest; whereas the first part, which consists in diagnosing the ailments which co-exist with the mental deficiency, is of immediate practical utility.

Let us note, in conclusion, the scientific trend of the present day. A large proportion of medical work is of scientific interest rather than of direct utility for the patient. A concrete example will explain our meaning. A severe shivering, a sudden elevation of the temperature, a dulness on one side of the chest, the presence in the same position of crepitant rales, a rusty, sticky expectoration--such is the syndrome by which a pract.i.tioner recognises an attack of acute pneumonia. He knows its duration; he knows the relief which will be produced by the application of poultices. To ideas such as these may be reduced all that is indispensable for the doctor to know in order to exercise his art. The post-mortem examination of the hepatised lung, its increase in density, the histological study of the engorged air cells and bronchioles, the researches upon the pneumococcus, its culture, its vitality--all this const.i.tutes a search into etiology and pathogenesis, whose aim is quite different.

The same distinction may be made in the medical study of defective children. And from this point of view the results which at first seem of secondary importance reappear in the foreground. This is the case, for example, with the stigmata of degeneration. It would be unreasonable to attribute to them an individual value, and to utilise them for arranging children serially in the order of their mental deficiency; but in the work of synthesis they are decidedly significant, since their study leads one to consider them either as the effects of, and therefore as witnesses to, alterations in the nervous system, or as the consequences of causes sufficiently powerful to have modified that system.

One would not deny all practical bearing to such investigations of pathogenesis. It is a mistake of Tolstoy to regard them as the pastime of refined dilettantes. When the biological study of defectives leads to this idea, that the mental weakness of the defectives, like the peculiarities in the character of the ill-balanced, is the result of degeneration--the result, for instance, of the alcoholisation of a people--it will quickly result in measures of social hygiene.

The point is, however, that this second part of the work cannot, in our opinion, be carried out under the same conditions as the first.

One would like to believe that, in making observations upon heredity and stigmata, the doctors are collecting, in their daily work, materials for a great scientific work which will be produced by degrees. No doubt all their schedules may some day be extracted from the drawers in the office where they will sleep for a long time; but with what object will they be taken out, if not to compile statistics of doubtful value? The truth is that scientific investigation cannot be carried on automatically and collectively. There is always a personal element which is independent of all administrative prescription. What use can be made of observations which are often merely a collection of paper? If we are some day to understand the role of heredity, of alcoholism, of insanity, of poverty, in the production of defective children, it will be necessary for someone, who wants to do a really good piece of work, to set aside all these equivocal doc.u.ments, and go straight to the facts, collecting his information at first hand and in a critical spirit. Scientific work can be done in no other way. When it is done otherwise it is worth nothing.

We therefore suggest the following schedule for the medical examination of defective children. The schedule includes two parts--one part optional, because it is only of indirect interest; another part which is obligatory. None of the questions in this part should be left unanswered, and the doctor will also give the instructions which he thinks ought to be followed.

MEDICAL SCHEDULE.

Date of examination: Height: Name and date of birth of child: Weight: